R-6431 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6431
INSPECTION DIVISIONPERMIT EXPIRATION -
REROOF PERMIT (408)tT7-8228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN IN DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
De eAe RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ N yes-I untlerstand that e
' NAME roof assembty is reQwed.
rQ /qy� NO ❑ Initial I.C.B.O.A
ADDRESS / EXISTING ROOF COVERING
PHONE — ( - NUMBER OF EXISTING COVERINGS OK�
CONTT
NA ESQ TO BE REMOVED 70 BE RETAINED
ADDRESSLg
TYPE OF ROOF COVERING
CITY a ZIP— <f✓CS EXISTING
PHONE /.
BUILT-UP ROOF - ❑
LICENSE
NUMBER "719 22 Z, ASPHALT SHINGLES ❑
LICENSEDeduncelTRACTORS DECLARATION 9(commencing
I hereby inion Chet I ern Ilanress under fessi n o Chapter B s IsInwith Section WOOD SHAKES ItKS��` `,��(/•r/')
7000)of Division 3 0l the Busineea eM Profession Code,en0 my Ilcenea le In full brce end
effect.
G 3 W K 22 2 WOOD SHINGLES /
Date Gaes Uc.Number ! �—
Date CBUILDEr
OTHER(SPECIE)') �,
OWNER-BUILDER ConR DECLARATION - PROPOSED
1 hereby eXIrmBu Business
am exempt from the Code: Any gra or coup Lew is the fcAlauires np reason. 7
(Sec.70315,r,Inpr es entl Ptah,or repitanAny dry or county which rewires a permit toESHINGLES
construct,ober,Improve,d file asi or repeat ementructure,prior toe euarce,oleoeequlree the ❑of theenl for crcn p icen to La a slpnetl statement incl he le Ikeneio pirnnuant 000)ofto the prwofMeofthe Contractors License Lew(Chapter S(comm mgtgweh Section me b of Divisionthe 3 of the
exa ptio entl Probsekrm Coda)or the.he la exempt tart fora perm the acts ler the enegetl' Sa cMI pamlyn. of not ore ru Nan hundr d anycolla epplfcant ler a permit euaecta the eppllcent toe cMl penalty of not moa thn INa huMred tlollem(5500)J:
❑I,as owner of the property,or my employees with wages as their sale compensation,will do
the work,antl the structure Is trot In.eMed or offered for sale(Sec.7044,Business antl Prates.slona Code:The Contractors License Lax does not apply to an owner of property"a builds or
Improves thereon,and who does such wok himself or through his own employees,prodded that El
such Improvements are not intended or offered for sale.If,however,the building or Improvemem '
Is aokd within one year of completion,the owrrer•bulker will have Me burden of proving that he tlld El
build or Improve W purpose of sale.). ,
❑I,as owner of the property,em exdua wly contracting with licensed contractors to construct
the project(Sec.7044,Business and Profession,Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who builds or improves thereon,ark who contracts for such projects
with a cwimctorms cermd pursuant to the Contractors License Lew. - PROVIDE MFGR.INSTALLATION SPECS.
L]I am exempt under Sec. ,B 8 P.G for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
_ reby aHl ma uMer.penelty of perjury one of the following declaration:
neve antl will meln.ab a Cenlficate of Conaem to self-I ure for Worker's Compensation, Building
and for by Section 37W of the Labor Code,for the performance of the work for which this g
par���mbIII he"and will maintain Worker's Compensation insurance,as rewired by Section 37M of �v SO Seismic
in bor Code,ler the performance of the work for which this parmlt B Issued.My Workers
enaetlon Insurance canter and Policy number am: Total sal.-Z—
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N El
(This section rIeW mt Ee completed lf the permit Is for one hundred dollars($100)or Ierl O ,_
I certify Chet In the performance of the work ler which this permit W Issued.I shell wt employ
any.person In arty manner so ea to become subject to the Workers'Compensation Laws of Cath All roots shall be inspected prior to any roofing material being
femaa. installed. If a roof is installed without first obtaining an
Dote Appacant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cortlficate of Exemption,you should become Applicant understands and will I with all non cin[
Subject to the Workers'Compenaetkn proWslons of the Labor Code,you must forilmith complyPP comply Y P
with Such provisions or this pe mit analGbe deemmi revoked. soy gulations.
I certify that I have read this application entl state that the above Information le correct.I agree
.to compy with all dry ara county ordinances aMstate kwa reusing to building constwwon,arc! All ro coveriri be class or better.
hereby authorize representative,of this dry to enter upon th,alfic�mewomw property ler In- n
speNcn pumoaea. f/
(We)apnea to save,IM¢mniry,aM keep harmlem the Cary of Cupertino ageW1 Ilabilliles,
costs ets antl expenses which may In any way accrue against said Clty In• coneepuence IGNATURE OF APPLICANT DATE. cf the gr of this Psrmd.
PRE-INSPECTION:
ION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE - INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL -
INSP. DATE INSP, DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL'BE PROVIDED FOR INSPECTION
OFFICE COPY